Design considerations in a clinical trial of a cognitive behavioural intervention for the management of low back pain in primary care: Back Skills Training Trial

Systematic Review of Costs and Effects of Self-Management Interventions for Chronic Musculoskeletal Pain: Spotlight on Analytic Perspective and Outcomes Assessment

BACKGROUND

Evidence for the cost-effectiveness of self-management interventions for chronic musculoskeletal pain (CMP) lacks consensus, which may be due to variability in the costing methods employed.

PURPOSE

The purposes of the study were to identify how costs and effects have been assessed in economic analysis of self-management interventions for CMP and to identify the effect of the chosen analytical perspective on cost-effectiveness conclusions.

DATA SOURCES

Five databases were searched for all study designs using relevant terms.

STUDY SELECTION

Two independent researchers reviewed all titles for predefined inclusion criteria: adults (≥18 years of age) with CMP, interventions with a primary aim of promoting self-management, and conducted a cost analysis.

DATA EXTRACTION

Descriptive data including population, self-management intervention, analytical perspective, and costs and effects measured were collected by one reviewer and checked for accuracy by a second reviewer.

DATA SYNTHESIS

Fifty-seven studies were identified: 65% (n = 37) chose the societal perspective, of which 89% (n = 33) captured health care utilization, 92% (n = 34) reported labor productivity, 65% (n = 24) included intervention delivery, and 59% (n = 22) captured patient/family costs. Types of costs varied in all studies. Eight studies conducted analyses from both health service and societal perspectives; cost-effectiveness estimates varied with perspective chosen, but in no case was the difference sufficient to change overall policy recommendations.

LIMITATIONS

Chronic musculoskeletal pain conditions where self-management is recommended, but not as a primary treatment, were excluded. Gray literature was excluded.

CONCLUSION

Substantial heterogeneity in the cost components captured in the assessment of self-management for CMP was found; this was independent of the analytic perspective used. Greater efforts to ensure complete and consistent costings are required if reliable cost-effectiveness evidence of self-management interventions is to be generated and to inform the most appropriate perspective for economic analyses in this field.

Identifying potential moderators for response to treatment in low back pain: A systematic review

BACKGROUND

Identifying which patients with non-specific low back pain are likely to gain the greatest benefit from different treatments is an important research priority. Few studies are large enough to produce data on sub-group effects from different treatments. Data from existing large studies may help identify potential moderators to use in future individual patient data meta-analyses.

OBJECTIVE

To systematically review papers of therapist delivered interventions for low back pain to identify potential moderators to inform an individual patient data meta-analysis.

DATA SOURCES

We searched MEDLINE, EMBASE, Web of Science and Citation Index and Cochrane Register of Controlled Trials (CENTRALhttp://www.cochrane.org/editorial-and-publishing-policy-resource/cochrane-central-register-controlled-trials-central) for relevant papers.

DATA EXTRACTION AND DATA SYNTHESIS

We screened for randomised controlled trials with ≥500 or more participants, and cohort studies of ≥1000 or more participants. We examined all publications related to these studies for any reported moderator analyses. Two reviewers independently did risk of bias assessment of main results and quality assessment of any moderator analyses.

RESULTS

We included four randomised trials (n=7208). Potential moderators with strong evidence (p<0.05) in one or more studies were age, employment status and type, back pain status, narcotic medication use, treatment expectations and education. Potential moderators with weaker evidence (0.05<p≤0.20) included gender, psychological distress, pain/disability and quality of life.

CONCLUSION

There are insufficient robust data on moderators to be useful in clinical practice. This review has identified some important potential moderators of treatment effect worthy of testing in future confirmatory analyses.

Treatment compliance and effectiveness of a cognitive behavioural intervention for low back pain: a complier average causal effect approach to the BeST data set

BACKGROUND

Group cognitive behavioural intervention (CBI) is effective in reducing low-back pain and disability in comparison to advice in primary care. The aim of this analysis was to investigate the impact of compliance on estimates of treatment effect and to identify factors associated with compliance.

METHODS

In this multicentre trial, 701 adults with troublesome sub-acute or chronic low-back pain were recruited from 56 general practices. Participants were randomised to advice (control n = 233) or advice plus CBI (n = 468). Compliance was specified a priori as attending a minimum of three group sessions and the individual assessment. We estimated the complier average causal effect (CACE) of treatment.

RESULTS

Comparison of the CACE estimate of the mean treatment difference to the intention-to-treat (ITT) estimate at 12 months showed a greater benefit of CBI amongst participants compliant with treatment on the Roland Morris Questionnaire (CACE: 1.6 points, 95% CI 0.51 to 2.74; ITT: 1.3 points, 95% CI 0.55 to 2.07), the Modified Von Korff disability score (CACE: 12.1 points, 95% CI 6.07 to 18.17; ITT: 8.6 points, 95% CI 4.58 to 12.64) and the Modified von Korff pain score (CACE: 10.4 points, 95% CI 4.64 to 16.10; ITT: 7.0 points, 95% CI 3.26 to 10.74). People who were non-compliant were younger and had higher pain scores at randomisation.

CONCLUSIONS

Treatment compliance is important in the effectiveness of group CBI. Younger people and those with more pain are at greater risk of non-compliance.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN54717854.

Self-efficacy and fear avoidance beliefs in chronic low back pain patients: coexistence and associated factors

A cross sectional study was conducted with the objective to assess the coexistence of self-efficacy and fear avoidance beliefs and establish the associated factors. Data collection was performed (215 individuals with lower back pain at three health services and two industries). The following instruments were used: Tampa Scale for Kinesiophobia, Beck's Depression Inventory, Piper's Fatigue Scale, Oswestry Disability Index, and the Chronic Pain Self-Efficacy Scale. Wilks' lambda test was performed, followed by MANOVA model to assess the effect of self-efficacy beliefs and fear avoidance on independent variables. Most subjects were women (65.1%), 45 years of age or younger (50.7%), with a family income between $450 and $1,350 per month (49.3%). Depression was present in 21.4%, fatigue in 29.3%, and disability in 68%. The average (standard deviation) of self-efficacy was 180.8 (60.4), and fear avoidance was 42.0 (11.5). A significant negative correlation was observed between the total score of both beliefs. The Wilks' lambda test showed that gender, income, depression, disability, and fatigue were significant and were included in the model. In the Manova analysis, low self-efficacy was associated with lower income, fatigue, depression, and level of disability (p < .001). High fear avoidance was associated to the male gender, lower income, depression, and level of disability (p < .001). The analysis of the confidence areas showed that a reduced self-efficacy and increased fear avoidance are related to an increased level of disability (p < .001). Specific intervention strategies must be implemented change these beliefs.

Complementary and alternative medicine (CAM) providers' views of chronic low back pain patients' expectations of CAM therapies: a qualitative study

Background

Some researchers think that patients with higher expectations for CAM therapies experience better outcomes and that enthusiastic providers can enhance treatment outcomes. This is in contrast to evidence suggesting conventional medical providers often reorient patient expectations to better match what providers believe to be realistic. However, there is a paucity of research on CAM providers’ views of their patients’ expectations regarding CAM therapy and the role of these expectations in patient outcomes.

Methods

To better understand how CAM providers view and respond to their patients’ expectations of a particular therapy, we conducted 32 semi-structured, qualitative interviews with acupuncturists, chiropractors, massage therapists and yoga instructors identified through convenience sampling. Interviews were recorded, transcribed and analyzed thematically using Atlas ti version 6.1.

Results

CAM providers reported that they attempt to ensure that their patients’ expectations are realistic. Providers indicated they manage their patients’ expectations in a number of domains— roles and responsibilities of providers and patients, treatment outcomes, timeframe for improvement, and treatment experience. Providers reported that patients’ expectations change over time and that they need to continually manage these expectations to enhance patient engagement and satisfaction with treatment.

Conclusions

Providers of four types of CAM therapies viewed patients’ expectations as an important component of their experiences with CAM therapy and indicated that they try to align patient expectations with reality. These findings suggest that CAM providers are similar in this respect to conventional medical providers.

The access randomized clinical trial of public versus private physiotherapy for low back pain

STUDY DESIGN

Pragmatic randomized clinical trial.

OBJECTIVE

This study investigated differences in the clinical outcomes of public physiotherapy (public PT) versus private physiotherapy (private PT) for general practitioner-referred patients with acute and chronic low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Health care setting (i.e., public or private) has been found to influence the course and clinical outcome of common diseases. Despite the international burden of LBP, the effect of health care setting on clinical outcomes has not been investigated in this population.

METHODS

One hundred sixty consenting patients, who were referred for physiotherapy for LBP by their general practitioner, completed the Roland Morris Disability Questionnaire (primary outcome), Short-Form 36 v2, Fear Avoidance Beliefs Questionnaire, Back Beliefs Questionnaire, EuroQol EQ5D, and Patient Satisfaction Questionnaires. The patients were stratified (acute LBP: ≤ 3 months, n = 55; chronic LBP: > 3 months, n = 105), randomly allocated to receive public PT (n = 3 hospitals) or private PT (n = 12 clinics), and followed up at 3, 6, and 12 months postrandomization.

RESULTS

Repeated measures analysis of variance showed significant improvement over time for 9 predominantly biomedical outcomes: (i) Roland Morris Disability Questionnaire at 3 and 6 months, (ii) Short-Form 36 v2 Physical Component Score, Bodily Pain, Role Physical, General Health, Vitality, EQ5D visual analogue scale, and weighted health index scores at 3 months, and (iii) the Back Beliefs Questionnaire at 6 months. The remaining 7 biopsychosocial outcomes showed no change over time, and the "between within" repeated measures analysis of variance showed no significant differences between groups over time for any outcome measures (P > 0.05). Independent samples t tests found no significant differences between groups in the mean changes in outcome measures from baseline at 12 months, apart from SF-36 v2 Role Physical (mean difference, 95% CI = 5.64 [0.860-10.428]; t = 2.337; P = 0.021) in favor of the private PT group. There were significantly higher levels of satisfaction with outcome of treatment in the private PT group (median [IQR]: public PT: 5.0 [2.0]; private PT: 6.0 [2.0]; Mann-Whitney U test = 1324.50; P = 0.020), but no differences in satisfaction with treatment or global perceived improvement (P > 0.05). The private PT group had a significantly shorter waiting time (mean difference = 39.79 days; 95% CI: 26.88-52.69; t = 6.121; P < 0.001) and treatment duration (mean difference: 23.48 days; 95% CI: 7.43-39.52; t = 2.909; P = 0.005) than public PT. Participants in both groups were treated with advice/education, manipulative therapy, and exercise therapy, with minimal use of cognitive behavioral approaches in either group. Physiotherapists in the private PT group had significantly more experience and more postgraduate qualifications than the public PT group (P < 0.005).

CONCLUSION

Despite differences between public and private PT regarding waiting times for treatment and therapist experience, there were no significant differences between groups in the majority of clinical outcome measure scores at follow-up, apart from SF-36 Role Physical and satisfaction with treatment outcome in favor of the private PT group.

Are we making progress?: the tenth international forum for primary care research on low back pain

STUDY DESIGN

Synthesis and analysis of presentation and discussion highlights, with a focus on emerging trends and promising new directions in primary care research on low back pain (LBP).

OBJECTIVE

To present a summary of findings, themes, and insights from the Tenth International Forum on Primary Care Research on Low Back Pain, a meeting of researchers designed to share the latest concepts, methods, and results of research on LBP diagnosis, treatment, and disability prevention.

SUMMARY OF BACKGROUND DATA

Earlier Forum meetings have developed several common themes and general conclusions. These are contrasted with the presentations and discussions at the 10th International Forum.

RESULTS

Major themes included concerns about the epidemic of chronic, disabling LBP, associated treatments, iatrogenesis, and the "LBP medical industrial complex"; the variability and complexity of outcomes and how their importance differed across patients in defining recovery and recurrence; the power of nonspecific effects, expectations, and therapeutic alliance; and the challenges of identifying important therapeutic subgroups. New research addressed early risk factor screening and linked intervention, nonmedical approaches to reframe the LBP problem and avoid unnecessary care, cognitive and behavioral aspects of LBP, and ways to train clinicians to implement these innovations. More appropriate use of longitudinal designs and a greater focus on implementation research was called for.

CONCLUSION

Although the field of primary care LBP research often seems to progress slowly, the Forum highlighted several important, promising developments that could substantially improve LBP research and primary care practice.

Contemporary low back pain research - and implications for practice

Each month, several journals contain reports on new ways of looking at low back pain-related risk and prognostic factors, new clinical interventions and suggestions for improved care. This is because back pain continues to be a vexing condition to manage. It often defies evaluation, diagnosis and treatment, and is associated with considerable individual suffering and negative societal impact. Although reviewing new and promising strategies is always interesting and gratifying for the reader, it is sobering to reconsider similar efforts over the past decades. Most new ideas for low back pain care have not proven to be effective when subjected to repeated rigorous and independent evaluation. New developments in epidemiologic and clinical understanding, and innovative approaches to non-medical management now appear to provide the best opportunities for improving outcomes. In this article, we review new perspectives and research studies that show promise, and suggest alternatives to current clinical and research paradigms.

The Back Disability Risk Questionnaire for work-related, acute back pain: prediction of unresolved problems at 3-month follow-up

OBJECTIVE

To assess the validity of the Back Disability Risk Questionnaire (BDRQ) to predict developing chronic back disability.

METHODS

Five hundred nineteen working adults (67% male) seeking outpatient care for acute, work-related back pain (<or=14 days) completed the BDRQ. After the initial medical evaluation, clinicians provided prognostic impressions in a 10-item questionnaire. Pain, functional limitation, and work status were assessed at 3-month follow-up.

RESULTS

In multivariate analyses, the presence of persistent pain, functional limitation, or impaired work status (31.4%) was predicted by six BDRQ questions: injury type, work absence preceding medical evaluation, job tenure, prior back surgery, worries about re-injury, expectation for early return-to-work, and stress. Classification accuracy at 3 months was 76.3%. Initial clinician impressions showed no multivariate associations with outcomes.

CONCLUSIONS

The BDRQ may provide prognostic information not observed in a routine medical evaluation for acute BP.

Therapists are ideally placed to create a collaborative self-management approach

A biopsychosocial, patientcentred approach and good governance are central to health-care philosophy. The core of rehabilitation today focuses on the management of chronic conditions. This has enabled a shift in therapy from a conventional therapist-centred model to a patient-centred one which emphasizes managing conditions rather than curing them. In terms of patient–therapist interactions, this has necessitated a move to a concept of collaboration where goals and strategies are jointly planned and negotiated. This is more than simple adherence to treatment guidelines; it incorporates the psychological as well as the social management of living with chronic illness (Newman and Mulligan 2004). Self-management is a highly skilled approach that can only be successful in a setting that encourages self-efficacy and a decrease in stress as a management aim, thus moving from a passive to a more active treatment paradigm for the patient.